In Committee I paid tribute to the civilised, constructive, yet combative Committee stage. This Bill embodies practical proposals to improve the National Health Service for the public. To this practical reform the contribution of the Opposition has not been so constructive. They have produced useful Green Papers, they have engaged in some interesting thinking aloud, particularly about hypothetical situations—for example, what might happen if it were feasible to bring the NHS within local government—and there have been a few good practical suggestions, but on the more difficult issues they have really never made their minds up about what should be done, and where they did appear to have made their minds up, they have changed them during the passage of the Bill, and will no doubt change them again. Uncertain as to what should be done, they have fallen back on vague criticism and generalised smears.

As a result, there has been a good deal of ritual rudeness about the Bill, but the area of agreement has, in fact, been large. On four of the six themes set out in the Explanatory Memorandum there has been no real disagreement. First, it is accepted that the service should be administered under new health authorities covering the whole range of care—not as an end in itself, but in order to ensure a better service for the patient, better use of resources and better opportunities for reordering local priorities in the interests of the relatively neglected sectors of the service. Although the Opposition have argued that this is only a transitional stage, they have not said either that the service could be brought under local government next year or when such a transfer might be possible.

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Secondly, it is common ground that we must provide for collaboration between the new health service authorities and local authority services and between the NHS and voluntary organisations. There was a little complaint about complexity, but there were no real suggestions for improvement.

Thirdly, the need to continue NHS responsibilities for medical and dental teaching facilities has been generally accepted, as has the wide range of health service powers and duties contained in the Bill.

Fourth, the establishment of the health service commissioners has been generally welcomed. Admittedly, some would have liked wider and some narrower terms of reference, but we think the balance in the Bill is right.

There has been a good deal of discussion of a fifth theme, that of how best to ensure that the views of the health professions and staff generally are given their full weight in the planning and management of services. Discussion has, however, underlined the view we took in the Bill that, because of the professional complexity of the service, it would be quite impossible adequately to represent the views of the various professions and staff groups on the health authorities themselves. Although the Opposition began by advocating professional representatives on area health authorities, their position had shifted considerably by Report stage in this House.

The main centre of disagreement has, of course, been the sixth theme—the means in each area of representing the interests of the community. We have seen no alternative, at least in the foreseeable future, to this being a national, centrally financed service, in which the basic democratic accountability is through Ministers to Parliament.

Area health authorities, working through their health districts, with the new officer, the community physician, and the new mechanism, the health care planning teams, to help them will identify the health needs of their public and organise to meet them. There will now in each area be systematic efforts over the year to serve the health needs of all—the acute, of course, but also the non-acute, the afflicted, the disabled the
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elderly—the other groups which are in all our minds.

The regional and area health authorities will be staffed by expert officers and will be led by chairmen and members chosen because of their interest in the National Health Service and their drive, judgment and humanity. They will not manage in the narrow sense. They will guide their officers, who will carry out the detailed work of administration. They will be intensely concerned with the public's views and needs, but the main voice of the consumer will be the 200 new community health councils monitoring the performance of the local health service and influencing planning and decision-taking by continuous dialogue with the area health authorities.

Most community health council members will have at least as great an influence on the service as most hospital management committee members have today. Including community health council membership, the opportunity for lay members will be as great as now.

The Opposition's alternative is to increase the proportion of local authority members on health authorities. We have about 25 per cent. They began at a third and ended at over a half. Of course, local authority members have an important rôle, as providers of services which must interact with health, providers of social services, housing, education.

The Opposition are not saying that health authorities should be elected not that here and now the National Health Service should be run by local government. They are saying that a few more local authority members—busy men and women with huge direct responsibilities of their own—will transform the service and somehow make the health authorities automatically more responsive to the real needs—not only the obvious but the not so obvious needs—of the public.

Here is no issue of principle. Putting the National Health Service under local government would be such an issue. That is not the Opposition's proposal. They would substitute for the community health councils, half of whose membership will come from enthusiastic representatives of those very voluntary bodies most in need of an effective National Health Service, an increase in the proportion of local authority members.

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It will be hard enough for the four local authority members we propose for each authority. They will be nominated, we hope, because of their responsibility for large local authority services crucial to the National Health Service. They will be very busy people if they are to contribute effectively to both bodies. There is not an unlimited supply of effective councillors with time to be effective both in local government and in the National Health Service.

The service will, I believe, be less bureaucratic because the area health authorities will have far more power than exists in hospital management committees at present. The management structure which the Opposition enjoys smearing—has been carefully designed for the huge, humane purposes of the National Health Service—to involve the doctors and nurses in the management and to enable, through health care planning teams, all relevant skills to plan together for any aspect of the service.

There have been legitimate anxieties about the effect of untried changes. We are necessarily breaking new ground in a number of ways, for example, in organising a comprehensive service on an area basis matching local government, in new management arrangements, and in new forms of consumer representation. We are doing so on the basis of study of past experience and exhaustive examination of the alternatives. We have good reason to believe that they will achieve the results expected of them, and improve the service to the patient. But we shall need carefully to monitor their operation and make adjustments if necessary.

Reorganisation will undoubtedly involve a great upheaval for the administration of the service, and the practical problems of the transition will place a heavy additional load on the existing staff. Every effort will be made not only to maintain services but to continue their development. We have to recognise, however, that some work on desirable developments will have to be deferred until after reorganisation has been carried through. This is a cost we shall keep to the minimum but it is worth facing for the benefits we can derive from reorganisation. It will be
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a matter of pausing in order to advance the better.

Reorganisation will enable the management and devoted staffs—medical, nursing, paramedical, technical, ancillary and administrative—to provide a better, more sensitive service for the patient, better shaped for all the local needs.

I begin by making one brief point of agreement with the Secretary of State. It was certainly an agreeable and civilised Committee stage. Had we had the pleasure of the right hon. Gentleman's company for a little longer in Committee than we did, it may be that he would have understood some of the issues dividing the two sides a little better than he does at the moment.

Secondly, I express two regrets on which I may carry the right hon. Gentleman with me. The first is that, for all their apparent desire to deal with community politics, there does not seem to be a single Member of the Liberal Party here to discuss what is, after all, the most important reorganisation of the National Health Service that we have had in 25 years.

My other regret is that there should have been so little reporting of the Bill's various stages in the Press. Our debates showed very clearly the deep issues that there were and involved Parliament with them.

Basically there have been three major centres of controversy. The first is the whole managerial concept embodied in the Bill's proposals, which struck us when we read the Bill and strikes us now as undemocratic and self-defeating. The old National Health Service was hospital-dominated. The new service will also be hospital-dominated. I noticed that the Secretary of State mentioned community health councils. It was the right hon. Gentleman who spoke about changes of mind. Rather late in the day and after several changes of mind on his side he finally soldered on to the ramshackle structure of the new service a community health council concept different from the one first introduced. But to our mind even in its latest form it is one which could not by any stretch of the imagination be called democratic. The
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new health service will emerge inflexible and incapable of constructive change.

The second point of controversy is that the new health service, like the old, remains Whitehall-administered. From time to time we were given two reasons against local government control. Today the Secretary of State mentioned what appeared to be a third reason. The first was that finance would have to come from central Government funds. It was said, therefore, that there would be no real local independence. The second was that the medical profession would refuse to co-operate.

As to the first argument, there is hardly one aspect of local government today which does not require central Government finance. If one considers education as an example, central Government finance has a dominant share. But no one could doubt that local government in this connection is as independent as ever.

As to the second, in Committee the hon. Member for Reading (Dr. Vaughan), himself a distinguished member of the medical profession, made a very important announcement when he said that, while his profession would not wish to be bedevilled by party politics when doing its work, it would be willing to co-operate with whatever pattern of health service Parliament decided upon, whether or not it was local government controlled.

Neither of these objections should have prevented the Bill from a move in the direction of local authority control preferably by a greater proportion of membership of the relevant authorities coming from local authority appointees, whatever proportion might have been chosen. That could have been a matter for argument and there could be changes of mind when considering the total number of members of a given local authority. But whether they ought to have a dominant share was undoubtedly a major matter argued by Opposition hon. Members. In addition, we said that the actual workers in the health service, who had lavish tributes paid to them by hon. Members of all parties, were as little represented in the running of the new health service as they were in the old and that this was a matter which should have been remedied.

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The third reason concerns the structure of the authorities. The obvious unit of operation in the health service is the health district. The Grey Book says that. The foolish reorganisation of local government last year has made it impossible to create an efficient health service. Thus, the area health authority has been inserted into this Bill as if the Redcliffe-Maud proposals were still in operation. This has created a series of anomalies which no amount of resilience will be able to resolve.

In London, for example, health and social services which ought to be operated at the same administrative level will now be shared among three or in some cases even four authorities. It is true that in the early hours of the morning the Under-Secretary described the situation in London as "the least damaging compromise that the Government could find." If the Government's verdict on their own reorganisation of the health service is that it contains the least damaging compromise they can find, our description is a shorter one: the Bill is a disaster.

Fortunately, it is not a Bill that will go on for ever. It will be swept away and forgotten in a short time, and the real reorganisation of the health service will be done by a Labour Government. For these reasons I call on my hon. and right hon. Friends to divide against the Third Reading.

I on the other hand wish to congratulate my right hon. Friend upon his success in unifying the National Health Service. All of us would agree that there is an inherent weakness in the present health service in that it contains overlapping services as a result of its being divided, like Gaul, into three parts. To avoid the waste involved with overlapping services, too much time of skilled people, doctors, nurses and others has been devoted to committee work. It seems to be the great achievement of the Bill to deal with this. Whatever the views of the right hon. Member for Deptford (Mr. John Silkin), which he might manufacture for a Third Reading Opposition speech, we are really on the same point.

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We have heard it said that the Bill is too managerial and not sufficiently democratic. This is based on a misconception of the function of democracy. It is not the function of democracy to take an active part in healing and the prevention of disease. The function of democracy is a responsibility to see that money voted to the service is sufficient and is not wasted. That can be done perfectly well by this House, the Select Committee on Public Expenditure and the Public Accounts Committee.

There is the other major function of trying to rectify abuses and to point to deficiencies in the service. This is where I see Section 9 and the community health councils being of value. This is the proper area for democratic control and for democratic stimulus in the service. There are too, in Part III, the health service commissioners.

I commend the main structure of the Bill and disagree with the line taken by the Opposition. I have spent many hours reading through various essays by Labour hon. and right hon. Members—I regret that the right hon. Member for Coventry, East (Mr. Crossman) is not here—who have made attempts to reorganise the health service. They were all far worse than this Bill. Should the Labour Party ever come into power and return to some of those old Green and White Papers, it will be a sad day for the National Health Service.

I want to ask my right hon. Friend for two assurances. I should like to be assured that we will have a statement on the guidelines of administration. I am convinced that there is much misery caused to patients and that there is a waste of public expenditure as a result of the failure to encourage small hospitals in local areas under the general practitioners. I know quite well that there are parts of the country where from time immemorial these have existed.

Unfortunately, through the attempt to concentrate on the large district hospital these smaller hospitals are becoming fewer and the links are not there. The damage to the patient, especially the elderly patient, is great. Some of the very old require nursing care that cannot be supplied in their home. What is happening at present in many parts of the country is that when these old people
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get to that state they are removed to hospitals far from their friends and relatives. The result is that they are not visited. This is bad for their treatment and wasteful for the country. I hope my right hon. Friend can give us an assurance that he will try to solve this problem in the reorganised health service. I believe that in every market town in a rural area there should be a small hospital under general practitioners looking after people who are convalescent from the district hospital, for looking after geriatrics.

The other assurance I seek is perhaps more modest. Nowhere have I seen or heard mention of freedom of clinical choice. There is a certain diversity of treatment allowed in the health service. Let us consider homeopathy. There are 383 beds for the homeopathic patients and 51,000 attendances. That is terribly small if we look at the overall total in Great Britain—500,000 and 10 million respectively. It is important to those who believe in this treatment rather than in the majority of treatments offered by the medical practitioners. Those who are keen on homeopathy are anxious, in view of what has been happening recently.

The Hahneman Hospital in Liverpool has been closed, and it is feared that there will be a withdrawal of facilities in the National Health Service. I ask my right hon. Friend to give the assurance that the rôle of the Royal London Homeopathic Hospital as a national centre will continue under the new service and that there will be a continuance of clinical choice.

I should like to remind the House of what Mr. Aneurin Bevan said on this subject at the beginning of the National Health Service. It shows the wise judgment of the man who introduced this service, however much we may differ from him in other branches of politics. He said:
Obviously, if the homeopathic hospitals are brought into the scheme it must be regarded as a principle of fundamental importance that their special sectarian and individual character must be preserved because for the people who believe in it that in itself will be a part of the therapy and the treatment. In trying to restore people to good health the spiritual as well as the physical aspects are of profound importance. That applies to Catholic hospitals and to all hospitals with the special characteristics. If they are to be brought in it must be the
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obligation of the regional boards in establishing their management committee to see that these management committees are of a character which maintains the continuity of the characteristics of those institutions. I think that I can give that absolute guarantee because otherwise it would be an emotional mutilation which nobody could possibly defend.
I think it is very important, therefore, that we get that assurance before the final stage of the Bill.

In conclusion, there was a short time when I looked after the health of this country. May I say how pleased I am that it is my party that has made this forward step in the National Health Service. Britain is pre-eminent in the world in its treatment of health. This is because it is something that all parties have shared in, but in particular it is because we have, I believe, the finest doctors, the finest nurses and the finest ancillary workers. Because there is such a good team there, I am confident in leaving the National Health Service in their able hands.

The right hon. Member for Thirsk and Malton (Sir Robin Turton) brings to the debate his profound knowledge as a previous Minister of Health and, of course, he puts his finger right on the common ground of agreement, and that is the unification of the tripartite system. It is because of that agreement that this side of the House, in Committee and elsewhere, was so forcible on the fact—and Green Paper mark I, Green Paper mark II, consultative document mark I, the consultative paper of the Government, I have studied the lot—that what started out as being a simplification emerged as a monster of bureaucracy and ended as a bureaucratic monster. What happened throughout the Committee stage, as my right hon. Friend the Member for Deptford (Mr. John Silkin) said, was that we were trying to bring some democracy to it. The previous health service brought in 10,000 lay people at various stages but this Bill provides for only 1,600.

I accept that, because the right hon. Gentleman is the expert. But
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he knows that for effective power he has 90 area committees in England, 14 regional boards with 15 members on each, compared with the old system. However, I do not wish to cross swords further on that.

I want to follow the right hon. Gentleman in paying tribute to the Committee. I have served on many committees since I have been here and I agree with him that this was one of the most civilised. I enjoyed very much the way in which the whole debate was conducted. I do not want to perpetuate the old story about the boat race, where everybody en my side rowed very well but stroke rowed twice as fast as anybody else. However, I want to pay a special tribute to my hon. Friend the Member for Pontypridd (Mr. John). This was the first time that I had worked with him, and he did much work behind the scenes which saved a great deal of time in Committee. I also want to pay a tribute to the Under-Secretary, who carried so much of the weight. I think the mantle of one of the great Tory parliamentarians, Rab Butler, must have fallen on his shoulders, because I know no other Member who can speak so sweetly and give the soft answer that turns away wrath and show so much sympathy and understanding while making no concessions whatever.

I am sorry for the right hon. Gentleman because during his term of office he has gained in reputation for compassion in many areas, but nobody except him and his colleagues likes this Bill. Everybody who knows anything about the matter is against it and only the managerial consultants whom the right hon. Gentleman employed accept it. The reason is that we were expecting the service to be totally restructured and all he has done is to move the furniture around. The greatest failure is that he was after integration but has failed to get it. In practical terms, instead of integrating the three types of doctors—the community physician, the family doctor and the consultant doctor—he has managed to leave them separate and has left intact the local executive council that was and re-named it as the new family practitioner committee. He has failed to integrate regional and teaching consultants. He has introduced in Clause 4 an entirely new principle of charging for prescriptions, in that for the first time there is a charge for preventive
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medicine whereas previously charges were only for treatment prescriptions.

The practical difficulties are enormous, and I think that the sympathy of the House will go out to the right hon. Gentleman in the next 12 months when he is trying to solve these. Already anomalies are emerging. It is difficult for this House to understand why, when it comes to a regional team, he is going to have a team of people all equal in status and with special knowledge but the administrative member of the team is going to get £40 a week more than the nurse and the regional nursing officers are going to get £2,000 a year less than the administrators. I hope that when the Bill finally gets under way the right hon. Gentleman will be able to solve this anomaly.

Already I am afraid that the National Health Service Advisory Committee is proving to be a managerial dictator. There is a whole series of jobs for which various people will not be permitted to apply; for example, those now in postgraduate hospitals will not be eligible for the posts in the new service. The right hon. Gentleman say that later on they will perhaps be permitted to apply; but what it amounts to is that when this service is established in whole regions of expertise doctors, nurses and administrators will not be permitted to apply for jobs within the new set-up, and I think this is bad.

Like my right hon. Friend on the Front Bench, I pray for an October General Election so that we can put this badly conceived reorganisation right before these new arrangements are fully in operation.

I find some difficulty in supporting the Bill. Indeed, I feel that I cannot support it when I consider the problems of the National Health Service and realise that the Bill will not do very much to solve them. They are problems of inadequacy and inequality, and nothing in this Bill is going to put them right.

The main inadequacies of the National Health Service are an inadequate supply of the right doctors, an inadequate number of nurses in the right place, and an inadequate amount of cash. Yet this Bill is going to concentrate on the redistribution and realignment of administra-
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tive and managerial services. If my right hon. Friend, for whom there is much respect in the medical service, could guarantee a supply of better administrators, and more administrators, we would be happy. But nothing in this Bill leads me to believe that we are necessarily going to improve recruitment to administration.

The service, as my right hon. Friend the Member for Thirsk and Malton (Sir Robin Turton) said, is dependent on the good will and ability of doctors, nurses and ancillary staff. Yet these people are going to have less to do with the running of the National Health Service in future. They are going to find their powers of control diminished. The new battle of disease will be led by the quartermasters from the supporting arms rather than the generals who have fought previously. We are going to have little check on their functions and ability because the only check is the voice or democracy.

My right hon. Friend the Member for Thirsk and Malton said that disease has nothing to do with democracy; but it has, because the voice of democracy can also be heard in local government chambers, in this House and, in the past, in hospital management committees and regional hospital boards. This voice is going to be stilled and its functions will not be carried out adequately by anyone else. Once we get people who are appointed by Whitehall they will be looking anxiously for their CBE or OBE and the New Year's Honours List. This means getting in the good books of those in authority, and they are going to decide what happens in the National Health Service.

That is why I feel it is difficult to support the Bill. We have not gone to the root of the matter, which is how to get the most money and the best doctors in places where they are needed.

I have never believed in this derogation of the teaching hospitals. I think we need centres of excellence, but there is kudos, professional amusement almost, and certainly professional satisfaction in working in the best centres. So there is a natural desire to work there. It therefore seems unreasonable that the people who work in those centres should also be paid very much more on the merit award
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system, whereby if one works in a teaching hospital where one has this special satisfaction, one gets greater rewards. They are getting it both ways.

Over and above this, those who work in the acute arms of medicine—in the surgery and in medicine itself—can do so much better than those who work at the dreary task of psychiatry, particularly those concerned with the mentally sub, normal rather than the mental abnormal. If we saw a process of a more even or, indeed, uneven distribution of the merit award so that the best doctors were attracted to the least favourable areas and branches of the profession, it would be so much better than the time that we have wasted on the Bill, which will cause turmoil where there should be tranquillity.

As well as the redistribution of doctors, we need the redistribution of nurses. Governments over the past few years have destroyed the thrill and satisfaction of nursing. We have replaced a service which was devoted to the care of the individual with a system of administrative grades, so that no longer is the ward sister the queen of all she surveys and no longer is it the peak of a nursing career to be a ward sister or practising matron. There are to be curious people called administrative officers who live tucked well away from the patients. No one will know the matron or the sister. The matron is to disappear. The nursing service has been destroyed. Bureaucracy has moved in here just as in the rest of the health service.

I turn now to preventive medicine. At Question Time today questions were asked about varying aspects of medicine—kidney disease, crippled children, abnormal children, and so on. We should be trying to see what we can do to prevent renal disease so that we do not have to worry about the kidney banks. Yet we allow women to have children in inadequate surroundings and treatment is inadequately followed up. Indeed, there is an enormous surprise when 20 years later people appear in the surgery suffering from a kidney disease.

Preventive medicine must be extended for the hospital service, the social service and general practice and into the factories. Now that both men and women work together and are equally potential
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candidates for the renal or other units, we should seek them out at their places of work. People in their mass are susceptable to propaganda. We should be able to persuade them to come forward and submit to screening. All the screening that we have is still only in the realms of private medicine. It should be extended and increased in the National Health Service so that we can pick out those who may have the disease before it becomes both costly and deadly.

The Bill is composed and written by well-intentioned people who have made a great impression over the last three years in their work for society, but it will not solve the needs of the general public. The patient will be no better off and local government will be no better off. We shall have bureaucracy where we had democracy. All in all, I think it would be better if we forgot the Bill.

I do not think that many hon. Members on this side of the House could better the panegyric delivered against his own party by the hon. Member for Norwich, South (Dr. Stuttaford). I differ from him in only one respect—namely, the amount of democracy that he assumed took place in the old health service. I believe that it was little enough. My strictures about the Government's new plans are that they further reduce the element of public control of the health service.

The right hon. Member for Thirsk and Malton (Sir Robin Turton), when he said that democracy should not interfere with healing or the prevention of illness, missed the whole point of the Bill, which is that it is necessary to have a health service apparatus. There are certain conditions which are not so much medical as social problems. Thus, in those conditions the siting of hospitals for geriatric patients, for mentally ill patients, and so on, is a vital concern of society. Similarly, the facilities of chemists and their availability is a vital concern of society. Where physiotherapy facilities are afforded to people is, again, a vital concern of society. If the right hon. Gentleman is suggesting that democracy should not impinge in those areas, he is doing a very good job of reducing the status and quality of our democracy. I believe that it must enter into those
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areas if it is to retain its relevance as a democracy.

Despite what the Secretary of State, in his winning way, said about there being more lay content in the new service than there was in the old, there is no doubt that the lay voice in the new health service will be reduced and will not be able to make its contribution to the running of the new service. This is a pity at a stage where I think most of us would have expected any reorganisation of the health service to have brought about more rather than less democracy. The Government have pre-empted the Crowther and Kilbrandon reports and other such measures which would have brought a sensible reorganisation of government tiers which might have been able to accommodate within an elected framework a health service which had to be put outside the elected basis because of the inadequacy of local government structure in the 1940s.

I want to concentrate my remarks on the effect that the Bill will have on Wales. We know that the regional tier as it exists in Wales is to be removed and replaced by the area health authorities, topped up by the Welsh Office. The present incumbents of the Welsh Office have elevated the instinct for self-preservation into a political philosophy.

I do not believe that the placing of the control of the new health service in Wales within the Welsh Office will result in getting the innovatory impetus that is necessary to make sure not only that medical care is adequate but that it continues to be adequate in future. The officials in that office will lack the energy and the expertise and, above all, the will power to initiate, to probe, to think and to improve. I do not think that we may expect from them the degree of superintendence of the performance of the area health authorities that will improve the quality of service to the Welsh people. Indeed, it is already commonly being said in health circles in Wales that we are entering the area of Welsh Office non-intervention. I believe that this will be profoundly damaging to the community.

Health care in Wales has improved in the last few years because the regional health authority, the regional hospital board, has adopted a philosophy of
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intervention in these matters. The intelligence units and the survey teams that the Welsh Hospital Board has set up have led to a pioneering by that board in those aspjects of medicine which impinge most directly upon society—waiting lists, children in hospital, and so on. The effect of the Bill will be to reduce that service. I believe that we shall see a slowing down of the innovatory impetus that has been introduced into the health service in Wales in recent years. There will be an absence of challenge to the innate conservatism of the medical profession and of the hospital service.

The forces of inertia in a service of this magnitude are always present. It requires a very determined effort by people—preferably democratically elected lay people—to overcome that inertia. I believe that that will be entirely absent.

The Minister of State will no doubt say that we in Parliament have a chance to check the performance of the Welsh Office. If, as I suspect, the era of non-intervention in area health authorities is with us, then the tenor of the answers will be known in advance. The answers will be bland and in low key. The Ministers will have their eyes on 3.20 p.m. rather than on the future. In short, I do not believe that, as at present organised, Parliament will give an adequate opportunity for Welsh Members to play a constructive and meaning-full rôle in the health service in Wales.

Therefore, it is entirely right, and a step of historic magnitude, that my right hon. Friend the Member for Cardiff, West (Mr. George Thomas) has committed the Labour Party to placing the health service within an elected Welsh Council at the earliest possible opportunity. It is important that the community should know that the health service, which is their health service, after all, is in the hands of people elected by them and answerable to them.

I believe this to be a giant step, but it is not the step which the Government have chosen. We have seen that in field after field their instinct has been to transfer powers from Parliament to a bureaucracy. This is a further example of that propensity. But no matter; we shall take away this sort of arrangement from the bureaucratic organisation and
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place it in the hands of democratic bodies, because we believe that the invigorating winds of democracy will make a service worthy of all our people and the pride of us all. I regret that the present organisation seems to offer little hope of either.

I agree with the hon. Member for Willesden, West (Mr. Pavitt) in the tribute that he paid to the hon. Member for Pontypridd (Mr. John), although I thought that the hon. Member for Pontypridd was not up to his best form this afternoon.

One of the conspicuous features about what we all accept was a very agreeable Committee was the performance of Opposition back-bench Members. They completely eclipsed their Front Bench speakers not in their charm but in their willingness to try to understand what the Bill was about. We do not expect Welsh right hon. and hon. Members to apply rigid logic. It is emotions rather than logic at which we expect the Welsh to be strongest. However, as a team, there was no attempt by the Opposition to understand what the Bill was about. Therefore, their criticisms of the Bill often missed the point.

The right hon. Member for Deptford (Mr. John Silkin) was quite unfair to my right hon. Friend the Secretary of State in his crack about his absences from the Committee. My right hon. Friend was not in the Committee the whole time. No one would expect that. But when he was in the Committee he showed a great deal of illumination.

We are all agreed that the virtue of the Bill and the common ground is the need for unification and that a totally local-government-based health service is not possible at this stage. Although the Opposition seemed to waver a little about this, they did not argue or expect that this time around we would have a wholly local government service, such as we should like to have in the long run and certainly as I should like to have.

What the Opposition have failed to do justice to is the exceptionally rigorous nature of the system that is put forward. Most great administrative reforms start with a great deal of logic. As they pro-
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gress through the House the logic becomes more and more diminished. One might apply that remark to our local government reform. Concessions are made in response to various interests. The original philosophy becomes blurred. As a result, one gets something that is a half measure.

A conspicious feature of the progress of the Bill is the way in which its logic has been very rigorously maintained. Whatever one may think about the whole approach of my right hon. Friend, one has to acknowledge that it has about it a coherence which is very rare. Looking at the pattern from top to bottom, one can see that it is entirely consistent. What the Secretary of State set out to do has been achieved to the "nth" degree. The basis of this logic is the belief that one must have a clear allocation of responsibility.

The Opposition constantly argued for the injection of more local government representation at different tiers, particularly the area tier because that is where the main operating force of the scheme is to apply. But the Opposition never got to grips with the question of what exactly these local government representatives were meant to be doing. Were they meant to be there simply as good chaps who knew about the community and, therefore, could say things which would relate to what people were thinking, or would they be there representing local government? To the best of my recollection, we heard nothing about how these local government representatives would report back to their local authorities, or whether they would report back. The Opposition did not think that through.

The pattern chosen by the Secretary of State is in no sense undemocratic. In this pattern democracy is placed very firmly at the top.—[Interruption.] That is the point at which the democratic contact is made. It is no good hon. Members laughing at that because that is exactly the structure which their hero Aneurin Bevan put forward when he proposed his scheme for the National Health Service.

Accountability has to lie somewhere. The Opposition were constantly arguing for schemes which would blur accountability and make it impossible to know who was responsible democratically. In this scheme it is exactly clear who is
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democratically accountable. It may well be that Parliament will have to give some thought to whether it is equipped to act as a sufficient check on the Secretary of State in this structure. It may be that the Expenditure Committee will have to think very hard, in view of the heavy concentration on the management of the health service on the Secretary of State, about whether there should be a tighter means of scrutinising what he is doing. Those are legitimate questions for parliamentarians to ask. But at least we have a system in which it is clear who is to decide what at each point.

It is very foolish to run down the importance of management, as hon. Members did time and again and as my hon. Friend the Member for Norwich, South (Dr. Stuttaford) has just done. The truth is that the weaknesses of the health service have not been on the whole clinical weaknesses. Most of us would agree that, as a nation, we are fairly lucky in our doctors and nurses and in the standard of medical care as a whole.

But one knows only too well that the weaknesses come from the way in which the whole system is organised, from the waste of resources and the failure to relate people and bodies in an effective framework. As a result, we have all the problems which are only too familiar. Far too many people spend far too long waiting for operations. There is a slack-ness in the way in which the scarce resources have been used.

The importance of the managerial framework put forward by my right hon. Friend represents a serious attempt to overcome those difficulties. As the dreaded grey book makes clear, the object of this management is simply to make sure that better health care is provided. The stress on management is exactly right. The managerial framework is certainly direct in the sense that accountability is clearly expressed at all points, but it is also very subtle framework very much tailor-made to the problems with which it is concerned.

Some hon. Members of the Opposition kept making the point in Committee that it was a business concept that was applied to this sacred thing called health. It is not just a typical business blueprint. It certainly bears some things in common with the sort of McKinsey pattern
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that is becoming familiar, but these consensus committees have come up with something which is definitely tailor-made to the problems that we have to face. The essence of this is that instead of having a kind of chief-executive-type hierarchy with a formal, family-tree chain of command, one has a rotating system where people with specialist skills are the people who will be in the strongest position to influence decisions. Surely that is what we should be looking for.

I do not know how this scheme will work out. No doubt there will be many changes needed in the pattern put forward, particularly in the organisational blueprint. There will be a great deal of trial and error. But as a whole the scheme represents one of the bravest, most logical and rigorous approaches to public administration that we have seen for a very long time.

I enjoyed very much the speech by the hon. Member for Norwich, South (Dr. Stuttaford). I do not intend to follow him because I am convinced that he is following me and his speech was in the best traditions of the Norwich Socialist movement. Coming from Norwich, that is a compliment. However, I do not wish to indulge in party manoeuvres now.

My feelings about the Bill as expressed on Second Reading still remain. There is too short a period between the Royal Assent and the appointed day. Like many of us who are involved in hospital management work, I am in touch with our officers and I know the strain that is being put upon them. It is true that the health service administrative staff face the possibility of considerable change, not only in administration hut in their home lives and in uprooting of their families. That degree of uncertainty added to the further aggravation of the improved salary scales is bound to cause strain to all those principally involved. It is not only causing strain. I have found a degree of anger now being expressed about the improved salary scale issue.

There is a point which I do not understand and which is not in the Bill. It concerns the imposition of a ban on membership of the new-committees on anyone over the age of 65. To me that is utterly ridiculous because at a stroke this will
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remove from the health service lay administration a considerable number of experienced people who in the early stages of the new administration could provide the value of their experience. It was said that the advice received by the Minister was that any person over the age of 65 was most unlikely to become a member of the new committees, and it is a matter of regret, therefore, that a great deal of voluntary service may be lost, although I hope that those who are lost to the health service committees will take their experience and enthusiasm to the many leagues of hospital friends who could certainly do with their help.

Inevitably the Government will get their majority tonight, and so we face a considerable change in the health service. Whether it is for good or bad remains to be seen. I have grave doubts about the Bill, but, whatever happens, I believe that at least the changes must be given a fair chance to succeed in spite of the shortcomings about which we have expressed our disagreement. I go further and say that the Minister may rest assured that those of us involved in the health service at present are doing, and will do, all in our power to make the period of transition as smooth and effective as possible in difficult circumstances. That is a responsibility which we accept in spite of our doubts about the Bill. For the sake of the health service we shall do our utmost to ensure that these changes succeed.

I was not a member of the Committee but I have followed the progress of the Bill with a certain amount of care, perhaps principally because of representations made to me at an early date about the Government's decision that there should normally be only one area health authority for each non-metropolitan county. Many people in Lancashire felt most strongly, and still do, that in a county as large as theirs with a population of 1.3 million there was a case for more than one area health authority so that the difficulties of the liaison committees, which might arise from the boundaries of the area health authority not corresponding exactly with the local government boundaries, could be surmounted. I do not believe that all those
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who made representations about the matter to me have had their fears allayed.

There is one matter I wish to mention in the hope that the Government will perhaps keep the door open about it. A few days ago the Opposition moved an amendment which if carried would have written into the Bill the necessity for there to be one area health authority for each non-metropolitan county. The Bill allows the Minister by order to provide for more than one area health authority in special cases. I hope that if, after a time, my right hon. Friend comes to the conclusion that in a large non-metropolitan county there is a case for more than one area health authority he will not hesitate to make this administrative change.

We feel that there is a danger of the area health authority in a place like Lancashire being remote. We are, for instance, very concerned lest the area health authority based on Preston should fail to be responsive to the wishes of people, say, in my constituency to see that a small cottage hospital that has served the neighbourhood well for many years shall remain in existence. I do net wish to launch into a constituency speech but there are cases, and this is one of them, where a hospital has been built by public subscription and has a special place in the hearts of the people. I have such a hospital—a war memorial hospital—in my constituency. We seem to have a big enough battle under the present set-up to get the powers that be to acknowledge that if that hospital is to be pulled down to make way for a new road there is a case for another hospital to be built in the town.

Under the present system people's ears are all too often closed before we go to see them and they tell us that the Ministry is set upon the district hospital idea, and that it will be years before there is any possibility of us having a small cottage hospital in the town. I hope that the Minister will bear in mind what my right hon. Friend the Member for Thirsk and Malton (Sir Robin Turton) said. I am convinced that it is absurd and crazy to expect people to travel five, 10 or 15 miles to visit elderly relatives in a district hospital when they are there not to receive sophisticated treatment but merely to be looked after or to convalesce.

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I beg the Minister to make sure that one result of the new administrative setup is not that these area health authorities are remote and unwilling to respond to local demands. I hope that he will make sure that simply because the authorities have to look after a large area they do not forget that they are not just administrators, that sometimes money is not everything and that there is sometimes a case for what might superficially be less than the ideal administrative solution because it meets the overwhelming needs of a particular locality.

I have no further contribution to make to the debate and I apologise for intervening when I was not a member of the Committee. The Bill might appear to be a very technical Bill but it has been followed closely in many divisions and I am glad to have been able to make a small contribution.

I intervene briefly because I want to emphasise what still remains to me a serious defect in the Bill. It attempts to deal with the problems of the health service of the past and not of the present or the future. My deep regret is that it lacks the flexibility to enable changes to be made of the kind that the hon. Member for Norwich, South (Dr. Stuttaford) envisaged. The country faces immense and rapid social changes. Our health service must adapt itself to meet them. Half the major problems confronting the health service today are social problems intimately connected with the communities from which they flow.

I could not disagree more with the suggestion of the right hon. Member for Thirsk and Malton (Sir Robin Turton) that the democratic processes do not fit the problems of treatment and prevention. Indeed, without a modern interpretation of democratic involvement, we have no hope of dealing with the major issues of prevention of ill health and the development of high standards of healthy living in this country, as the World Health Organisation and other bodies have seen it.

I do not believe that we can achieve that object unless we can now, as we are reorganising local government, find a new link with the living community for which the health service is intended to provide.
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It is a living thing, and we are dealing with people—the awkward, difficult human beings that we all are. We shall find it more and more necessary to amend the provisions of the health service. We all share great pride in establishing it, and we all recognise how much help it has brought to the community, but we must recognise also the need to change it, and to change it in flexible ways that will enable us to keep a closer relation with the community which it serves. The Bill does not do that. Indeed, it fastens on us a new rigidity, in some respects greater rigidity than in the past, and that I deeply regret.

I thought that the most distinguished contribution that the right hon. Member for Deptford (Mr. John Silkin) made in Committee was not so much in his speeches—though I do not doubt that they were valuable—as in the fact that he listened to the debate and was prepared to absorb the arguments on both sides. He wanted to hear, and he wanted to form an opinion. This was a good example, not only to the Front Bench but to those on the back benches. But today he searched his mind for hyperbole and found the wrong word when he described the Bill as a "disaster". I cannot agree. It is undoubtedly a considerable step forward from the revolution that was started 25 years ago. It is a positive step forward, and I do not think that any hon. Member on either side of the House believes that it is not.

Perhaps the Opposition are telling the House and the country that they are not satisfied in all respects and feel strongly about certain aspects. To my mind, the Bill is not a curate's egg. It is an egg, but very good in many parts. The real test of the egg is how it will be cooked—and the chief cook, whether we like it or not, is my right hon. Friend the Secretary of State and his Department.

The management structure has been devised to bring together all three sides in the National Health Service. But it is then a question of interpretation. Shall we have a purely bureaucratic interpretation or a management consultant's interpretation? Or shall we have the type of feeling and understanding of the patient's needs of my hon. Friend the Member for
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Norwich, South (Dr. Stuttaford), a practitioner in the health service who has given many distinguished years of service? Shall we have his kind of understanding of what the public are seeking and wanting?

My right hon. Friend has said, practically every time he has spoken on the subject, about which he feels so strongly, that while he has been looking for a better management structure he has never forgotten that he wants a better and more sensitive service. That was the phrase which he used in the White Paper, and he used it again today. We must all agree with him on that.

The National Health Service is an enormous industry, employing many people. Throughout that industry, from the senior medical administrators, the chairmen of the regional health authorities, area health authorities, district councils, community health councils right the way down through the service, we must see that we do not lose sight of the fact that it is something much more than a management structure. It is a service sensitive to the public.

In a criticism of the Bill published very early on, Draper and Smart spoke about a good management tenet, that
the giving and sharing of information is an essential step in the process of participation.
"Participation" is a favourite word today. The health service must be one in which the consumer, the patient, feels that he is participating, making a contribution towards a service that he may one day want to serve him.

I hope that my right hon. Friend will examine the question of communication and what is to be done about it at regional or area level. Not enough public relations services are provided in the various tiers of the structure of management. It has been represented to me that it is not enough to have the professional services of hired men only at the regional level to provide the service of communication. It is sometimes very important to give the right communication at area or district level. The community health councils are a big step in the right direction, but we must be sure that there is a system of much closer communication with the public through more professional public relation services
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all the way down the line. It will mean having more people than just at the regional or area level, because at that level the public relations office could well be regarded as an office of the Secretary of State rather than of the health authority.

With that brief thought, I commend the Bill to the House, because I believe that it is good in many parts.

In the two minutes available to me I want to comment on the remarkable paradox that a Bill for reorganising the health service should have so many symptoms of sickness and be incubating what might be a virulent disease which could ruin the service. Having studied the Bill in detail, I am encouraged in that attitude by the almost unanimous opposition to the Bill of lay people who are interested in the service and contribute to its well-being.

I am tempted to follow the remarkable and exciting contribution of the hon. Member for Norwich, South (Dr. Stuttaford) on the preventive aspects, which must be stressed more and more, but there is one other matter that I should like the Secretary of State to consider. It is part and parcel of all legislation emanating from the present Government to give more and more power to faceless bureaucrats instead of extending it to ordinary people.

It is nonsense to say that the health service has nothing to do with democracy. Without a democracy it would never have been launched. Many Conservative Members took advantage of that democracy to try to prevent it from being born. In our society people are being driven out to the periphery, and bureaucrats are controlling from the centre. The health service is a fantastic service which I believe the British people want to see democratised even more. Given the opportunity, they would have made it an even better service than it has been up to now.

If the great vision of Aneurin Bevan, the author of the idea, without whom it would never have been launched, could have been continued in the 13 years of Tory Government, we should not be having this debate. It is regrettable that
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the Tories have not learnt from their errors and are still not prepared to trust ordinary people to run important matters affecting the lives of them all.

That is my fundamental criticism of the Bill. It tends to prevent ordinary people from having opportunities to make their contribution towards implementing the most civilised and greatest piece of legislation the world has ever seen.

It is a pity that the Third Reading debate on a major Bill of this character must be reduced to one and a half hours. We are fortunate that so many hon. Members have been able to take part. Apart from paying tribute to the contributions of my right hon. and hon. Friends, I pay tribute to the speech of the hon. Member for Norwich, South (Dr. Stuttaford), who gave the Secretary of State cause for serious concern.

The Bill creates the biggest shake up in the National Health Service since the service was established. It is two Bills in one. The Welsh reorganisation is not taking the same form as reorganisation in England. When my right hon. Friend the Member for Deptford (Mr. John Silkin) commented on the attendance of the Secretary of State for Social Services in Committee, he should have counted his blessings. The Secretary of State for Social Services has no more to do with the health services in Wales than has the Sultan of Brunei. It is not his concern. The Secretary of State for Wales is responsible for our reorganisation. It is disgraceful that he did not elect to serve on the Committee stage and did not honour us with his presence on Report, until we were going to the Missing Persons Bureau to see whether the right hon. and learned Gentleman was still alive. Now he elects not to answer the Third Reading debate. It is discourteous to Welsh Members and to Wales.

The right hon. and learned Gentleman knows that he and he alone carries responsibility in the Cabinet for the health service in Wales, but he adopts the aloof arrogance that the health service is not his concern. His attitude will be resented from North Wales to South Wales. He is not bearing the responsibility that he should. The Secretary of
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State for Health and Social Services also has the support of a junior Minister, but he does not run away from his responsibilities.

The Bill is a tale of missed opportunity. It is a foolish mistake. The Government look back to the 1940s instead of interpreting the mood of the 1970s. No one regretted the non-elected representative character of the health service more than did Nye Bevan, but his options were different from those that face this Government. He was faced with the option of either nominated committees or nothing. The right hon. Member for Thirsk and Malton (Sir Robin Turton), who was in full cry against our creating the National Health Service, supported the medical profession in its antagonism. The right hon. Gentleman has become a piece of history in this place—as I am rapidly becoming. He and I were here and voted in different lobbies when the National Health Service was created.

The Government had the chance of a lifetime to bring the National Health Service into line with the mood of the 1970s. They are greatly privileged people. Everyone knew that whoever won the last General Election would have the opportunity to restructure the NHS after 25 years. The long waiting lists for hospitals, inadequate facilities in hospitals, particularly in those for the long-term mentally sick, queue-jumping in the private sector and a host of other accumulated problems cry out for urgent attention, and the Bill does exactly nothing to solve those problems. It ignores them. The Government have missed the bus. In fact, they have gone in the wrong direction. Instead of democratising the health service they are creating an even stiffer, tougher, bureaucratic régime.

The trouble is that the Government do not like public control over public funds. They have shown this in the Water Bill and in other measures that they have introduced. The Bill creates a National Health Service based on remote control. The Secretary of State is the great "I am". Sometimes in chapel we sing the hymn "Jehovah, great I am". That is the philosophy of the Secretary of State for the Social Services and of the Secretary of State for Wales. All power is to be vested in the Secretary
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of State for Social Services. Every district committee, every area health authority and every regional health authority in England will have its mandate from the Secretary of State. The line is clear. He who pays the piper calls the tune. Because he controls the purse strings, these authorities are his puppets. Public opinion can say what it likes, but it is what the Secretary of State wants that these authorities will do and recommend. Even the community health councils, the supposed watchdogs for the consumers, lack any real independence. They, too, are dependent on the Secretary of State. They start life with false teeth; they have no bite. The Minister has made sure that he is the one who will control them.

The Bill is typical of Tory philosophy—"Keep the people in their proper place, we know what is best for them and we will tell them what is good for them." That is what the Government are practising.

As for the cost—and the reorganisation creates a structure similar to that of the Armed Services of the Crown with the Secretary of State as commander-in-chief and everyone below jumping to his orders—it will come out of the money that should have been spent on improved facilities.

We shall vote against the measure. We do not like its cumbrous, costly structure. We resent this system of remote control. It is the Government's day today, but our day will come, and we shall have our chance to rectify this monumental blunder.

May I first deal with the criticism made by the right hon. Member for Cardiff, West (Mr. George Thomas) of my right hon. and learned Friend the Secretary of State for Wales. I remind him that my right hon. and learned Friend spoke on Second Reading and also in the Welsh Grand Committee.

My right hon. and learned Friend spoke on health service reorganisation.

I also remind the right hon. Gentleman that when he was Secretary of State
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for Wales he gave his Minister of State responsibility for health and hospitals. If he will allow me to say so, that was made clear to all who heard his speech today. As to the relevance of the Sultan of Brunei, the right hon. Gentleman could tell us all a great deal more about that great country than we could tell him.

My right hon. Friend the Member for Thirsk and Malton (Sir Robin Turton)—a former Minister of Health—gave us a great speech today. My right hon. Friend the Secretary of State for Social Services and my right hon. and learned Friend the Secretary of State for Wales accept the principle of the community hospital in which general practitioners might remain responsible for the care of those of their patients who do not require the more specialist facilities of the district general hospital. They are preparing advice to health authorities on the rôle of such community hospitals.

My right hon. Friend raised other points, as did hon. Members on both sides of the House. As the time available to me is short, my right hon. Friend and my right hon. and learned Friend will write to them on the points they raised.

The debates on the Bill have shown that we all want a unified service which can deal comprehensively with patients' needs wherever they arise, without having to overcome the difficulties inherent in a compartmentalised administration. We all want a system in which preventive medicine and curative treatment—whether in the community or in the hospital—can be seen as complementary parts of the same service.

We would all be very happy if there were a practicable way of uniting even more widely, to bring the health service and the social services under one administration as well. But both sides of the House recognise that this is not at present possible. I think the House is satisfied that the arrangements we propose for very close collaboration between the two services are the best that can be devised at present and will at any rate represent a worthwhile step forward.

We all want a health service through which patients may be treated quickly and effectively in an efficient and humane way; and we all want to ensure that at the same time the service is sensitive and fully responsive to local needs. In all
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our aims we are, therefore, at one. Where we differ—and I do not underestimate the importance of that difference—is in whether these aims are best served by constituting bodies in which one tries to combine the responsibilities for representation and for providing an effective service; or whether it is better to recognise and provide for each of these functions in its own right.

The Government are convinced that to mix the two functions within the regional and area health authorities would lead only to confusion of rôles and to a poorer service. The needs of the communities are best represented through the community health councils, which the Government believe is the best way of giving to the patient, for the first time, a direct channel of influence on the running and planning of the service.

During the passage of the Bill we have readily agreed to changes which have shown our determination that community health councils shall be strong and effective, and we are satisfied that they will be a force to be reckoned with.

I cannot in the time available sufficciently deal with the criticism of the decision not to have a regional health authority in Wales. As I have said

I am the first to agree that the removal of the Welsh Hospital Board will mean that the Welsh Office and its Ministers will be more closely connected with the National Health Service and even more directly responsible to Parliament for its outside organisation.